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Task Force Recommends Against Routine Use of Estrogen To Prevent Chronic Diseases in Postmenopausal Women Who Have Undergone Hysterectomy

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The U.S. Preventive Services Task Force issued a new recommendation against the routine use of estrogen to prevent chronic conditions such as heart disease, stroke and osteoporosis in postmenopausal women who have undergone a hysterectomy. This recommendation is based on recent evidence from the National Institutes of Health's Women's Health Initiative clinical trial and other studies. The new Task Force recommendation is being published in the May 17 issue of the Annals of Internal Medicine.

In 2002, the Task Force found insufficient evidence to recommend for or against the routine use of estrogen alone to prevent chronic conditions in women who have completed menopause and had a hysterectomy. Now, after reviewing new findings from the Women's Health Initiative, the Task Force noted that, although estrogen can have positive effects such as reducing the risk for fractures, hormone therapy should not be used routinely because it appears to increase women's risk for potentially life-threatening clots that block blood vessels (venous thromboembolism), stroke, dementia and mild cognitive impairment. The Task Force noted that while the use of estrogen reduces the risk for fracture, drugs such as bisphosphonates and calcitonin are available and effective in helping prevent fractures in women diagnosed with osteoporosis. The Task Force concluded that for most women, the harmful effects of estrogen therapy outweigh any benefits for fracture and other chronic conditions.

In addition, the Task Force reaffirmed its earlier recommendation against the routine use of combined estrogen and progestin for preventing chronic conditions in postmenopausal women. Although the combination therapy may reduce risk for fractures in women diagnosed with osteoporosis and for colorectal cancer, it has no beneficial effect on heart disease and may even put women at greater risk for the condition. Other potential harms of combined estrogen and progestin include increased risk for breast cancer, venous thromboembolism, inflammation of the gallbladder, dementia and mild cognitive impairment. The Task Force concluded that the harmful effects of combined estrogen and progestin are likely to exceed the chronic disease prevention benefits for most women.

"The available studies have shown that hormone replacement therapy should not be used to prevent heart disease, cancer, and bone fractures," said Task Force Chair Ned Calonge, M.D., who is also Chief Medical Officer and State Epidemiologist for the Colorado Department of Public Health and Environment. "Women should use a shared decisionmaking approach with their clinicians to decide how best to prevent these conditions."

AHRQ Director Carolyn M. Clancy, M.D., agreed. "These recommendations expand the evidence base physicians depend on to deliver good quality medical care that meets the needs of individual patients," she said. "The evidence can also help women become better informed patients and decide with their clinicians what alternatives are available to prevent these chronic diseases."

The Task Force did not examine the effects of estrogen only or combined estrogen and progestin for the treatment of menopausal symptoms, only for the prevention of chronic disease. Menopause occurs in most women in the United States between 41 to 59 years of age, although the body's production of estrogen and progestin may begin to decrease years before. The average woman going through menopause has a 46 percent likelihood of developing heart disease over her lifetime, a 20 percent likelihood of stroke, a 15 percent likelihood of bone fracture, and a 10 percent chance of developing breast cancer.

The Task Force, which is supported by AHRQ, is the leading independent panel of private-sector experts in prevention and primary care. Its recommendations are considered the gold standard for clinical preventive services. It conducts rigorous, impartial assessments of the scientific evidence for a broad range of preventive services.

The Task Force grades the strength of its evidence from "A" (strongly recommends), "B" (recommends), "C" (no recommendation for or against), ("D" recommends against), or "I" (insufficient evidence to recommend for or against). The Task Force recommends against the routine use of unopposed estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy (a "D" recommendation). The Task Force recommends against the routine use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women (a "D" recommendation).

The recommendations and materials for clinicians are available on the AHRQ Web site at http://www.ahrq.gov/clinic/uspstf05/ht/htpostmenrs.htm. Previous Task Force recommendations, including screening for osteoporosis, high blood pressure, breast cancer, colorectal cancer and lipid disorders, and summaries of the evidence and related materials from the AHRQ Publications Clearinghouse by calling (800) 358-9295 or sending an E-mail to AHRQPubs@ahrq.hhs.gov. Clinical information is also available from AHRQ's National Guideline Clearinghouse™ at http://www.guideline.gov.

For more information, please contact AHRQ Public Affairs: (301) 427-1246 or (301) 427-1865.

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